Board Driven Quality Leading for Improvement Dale W. Bratzler, DO, MPH Professor and Associate Dean, College of Public Health Professor of Medicine, College of Medicine Chief Quality Officer – OU Physicians Group University of Oklahoma Health Sciences Center March 18, 2013 Overall Ranking Country Rankings 1.00–2.33 2.34–4.66 4.67–7.00 AUS CAN GER NETH NZ UK US OVERALL RANKING (2010) 3 6 4 1 5 2 7 Quality Care 4 7 5 2 1 3 6 Effective Care 2 7 6 3 5 1 4 Safe Care 6 5 3 1 4 2 7 Coordinated Care 4 5 7 2 1 3 6 Patient-Centered Care 2 5 3 6 1 7 4 6.5 5 3 1 4 2 6.5 Cost-Related Problem 6 3.5 3.5 2 5 1 7 Timeliness of Care 6 7 2 1 3 4 5 Efficiency 2 6 5 3 4 1 7 Equity 4 5 3 1 6 2 7 Long, Healthy, Productive Lives 1 2 3 4 5 6 7 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290 Access Health Expenditures/Capita, 2007 Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009). http://www.americashealthrankings.org/MT/2012 http://statesnapshots.ahrq.gov/snaps11/dashboard.jsp?menuId=4&state=MT&level=0 http://statesnapshots.ahrq.gov/snaps11/dashboard.jsp?menuId=4&state=MT&level=0 So why don’t we consistently provide high quality care? There are a lot of reasons…… • Medical science is evolving too fast for any clinician to keep up with – regardless of how good or smart they are • Historically, there were no incentives to adopt evidence-based care into practice • Disconnect between research and translation into bedside care • Systems not designed for safety and quality • No one was watching! (they are now) Explosion of Medical Knowledge Number of Articles (English) 3500000 3,051,188 3000000 2500000 2000000 1500000 1000000 500000 0 Articles indexed by the National Library of Medicine. http://www.nlm.nih.gov/bsd/medline_lang_distr.html It takes too long to get evidence into practice! The passive strategy of guideline publication and dissemination does not effectively change clinical practice – The time lag between publication of evidence and incorporation into care at the bedside is very long – Variations in care and delivery of care that is not consistent with evidence-based recommendations is well documented Bratzler DW. Development of national performance measures on the prevention and treatment of venous thromboembolism. J Thromb Thrombolysis 2010; 29:148-54. • 89 pages long; 1075 references • In reality, most physicians will never take the time (or have the time) to read the entire guideline • Even if they did, this only covers one aspect of preventing surgical infections. Why spend the time creating and publicly reporting national quality measures? Consumers are demanding transparency! • Consumer groups are demanding transparency – particularly about complications of care • When consumer groups have a consistent message, legislators respond… – The Medicare Program and other agencies then are required to create standardized measures that reflect the quality of medical practice 2 Examples: Legislative Mandates to Report Quality • Medicare Prescription Drug Improvement and Modernization Act of 2003 – Tied 0.4% of Medicare annual payment update to the public reporting of 10 measures of hospital quality • Deficit Reduction Act of 2005 – Tied 2% of Medicare annual payment update to public reporting of hospital quality measure and gave Secretary of HHS authority to expand measures http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=108_cong_bills&docid=f:h1enr.txt.pdf http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=109_cong_bills&docid=f:s1932enr.txt.pdf Accountability works! • There is good evidence now that when you spotlight performance on nationally standardized measures of quality (reporting them in the public domain), guideline adherence improves and performance improves rapidly! Public reporting and payment incentives change the way physicians and hospitals provide care and speeds adoption of evidence-based guidelines. Changes in National Performance Measurement and Reporting Drive Improvement! Abx 60 min Guideline Abx 97.6 100 Data source changed from independently abstracted to hospital self-collected. 80 60 40 97.1 95.5 20 1 2 Q 005 2 2 Q 005 3 2 Q 005 4 2 Q 005 1 2 Q 006 2 2 Q 006 3 2 Q 006 4 2 Q 006 1 2 Q 007 2 2 Q 007 3 2 Q 007 4 2 Q 007 1 2 Q 008 2 2 Q 008 3 2 Q 008 4 2 Q 008 1 2 Q 009 2 2 Q 009 3 2 Q 009 4 2 Q 009 1 2 Q 010 2 20 10 Q 20 1 01 * 2 Q 002 2 2 Q 002 3 2 Q 002 4 2 Q 002 1 2 Q 003 2 2 Q 003 3 2 Q 003 4 2 Q 003 1 2 Q 004 2 2 Q 004 3 2 Q 004 4 20 04 0 Q Percent Abx discontinued *National sample of 34,000 Medicare patients undergoing surgery in US hospitals during 2001. Bratzler DW, et al. Arch Surg 2005; 140:174-82. Improvement Door-to-Balloon Time Acute Myocardial Infarction Patients 0 10 20 30 40 50 60 70 80 90 100 Percent of patients with D2B time less than 90 minutes 2005 2006 2007 Year Hospital median 2008 2009 Patients Krumholz HM, Herrin J, Miller LE, Drye EE, Ling SM, Han LF, Rapp MT, Bradley EH, Nallamothu BK, Nsa W, Bratzler DW, Curtis JP. Improvements in door-toballoon time in the United States, 2005 to 2010. Circulation 2011; 124:1038-45. Krumholz HM, et al. JAMA. 2009;302:767-73. FYI - CMS Preference for Outcome Measures Over Process of Care Measures Hospital IQR Program FY 2013 FY 2014 FY 2015 Payment Score Payment Score Payment Score 25 30 70 45 30 20 20 30 30 Process of Care Process of Care Process of Care Patient Experience Patient Experience Patient Experience Outcome Outcome Efficiency Department of Health and Human Services. Centers for Medicare & Medicaid Services. 42 CFR Parts 412, 413, 424, et al. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals’ Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Final Rule.18 Federal Register, Vol. 77, No. 170. August 31, 2012. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/2012-19079.pdf. The Board’s Role in Driving Improvement Why Focus on Hospital Leadership? • Research suggests that more engagement of of hospital leadership (C-suite, boards, and physicians), in cooperation with other health care professionals in QI, is associated with higher performance in clinical care. – The active involvement and collaborative participation of top level leaders is essential – Hospital leaders must be given the knowledge and tools to address the issue 20 Hospital Leadership Survey Conclusions Better quality seems to be associated with: • Board oversight through regular reports – Focused (fewer items, Board QI committee involved in design) – More frequent – Used for operational purpose • CEO seen as a visible leader of quality improvement efforts • Executive compensation linked to quality targets 21 Jha A, Epstein A. Hospital governance and the quality of care. Health Affairs 2010; 29:182-7. 22 Among our nationally representative sample of chairs of boards from nonprofit U.S. hospitals, a little over half identified clinical quality as one of the two top priorities for board oversight. Jha A, Epstein A. Hospital governance and the quality of care. Health Affairs 2010; 29:182-7. 23 “Among the low-performing hospitals, no respondent reported that their performance was worse or much worse than that of the typical U.S. hospital, while 58 percent reported their performance to be better or much better.” Jha A, Epstein A. Hospital governance and the quality of care. Health Affairs 2010; 29:182-7. 24 Interacting with the Medical Staff about Quality Measures A few points to remember… • The Board is responsible for the quality of healthcare delivered and patient outcomes for care in their hospital – Ultimate authority in the facility – All healthcare providers in the facility must go through a credentialing process National performance measures are based on evidence! • All measures are developed by expert panels of physicians representing a broad variety of specialty societies – CMS and Joint Commission do not create the measures – they enlist physician specialists to review the best science • All measures are endorsed by the National Quality Forum – Includes open public comment on measures National performance measures are continuously updated. • Expert panels meet every three months to review the measures, review any newly published science, and to review all of the feedback we get from hospitals and clinicians across the country – Major changes are submitted to the National Quality Forum for re-review For example • Surgical measures are collected from more than 3700 hospitals nationally • 1.2 million operations submitted annually • 1600 questions per month are fielded from hospitals across the country Clinical Infectious Diseases 2013;56(3):428–9. My point for this discussion is…… • The national performance measures do apply to your patients! – They are based on best evidence with extensive physician input – Your patients are not sicker or different! • Process of care measures do not require risk adjustment • The outcome measures are adjusted for patient severity of illness Clinical Infectious Diseases 2013;56(3):428–9. My point for all of this…… • If a physician tells you that the measure does not apply to their patient or that they don’t agree with the performance measure, they are usually wrong. • Performance rates that approach 100% are achievable! • If there is controversy, you can always submit questions about the case to Mountain-Pacific Quality Health or through www.qualitynet.org If a physician has poor performance rates…. • And they are resistant change, ask them to provide guidelines that support their position – Get an external peer or expert to review (in my experience talking to hundreds of physicians across the country who don’t agree with our national performance measures, it is rare that anyone has ever sent me medical evidence that supports their position) You do not have to have a lot of cases to improve quality – a single case failure represents an opportunity to improve your system of care! So, if the target is usually close to 100%....... • In the setting of low-volume measures – You can consider treating case failures as sentinel events • For example, you should be able to give an aspirin to 100% of the heart attack patients that show up in your emergency room • If you miss with just one patient, it justifies doing a root cause analysis to see why – It may well be that the system failed Prioritizing Improvement • Focus on those topics that are common in your facility • Target measures with the greatest opportunity for improvement • Don’t try to reinvent the wheel – for most measures there are good tool kits available that can help you improve • Call on local resources Take change one case at a time. • When there is resistance to change, focus on one case – Show that you can provide care a different way and achieve good quality outcomes. – Find a champion – Foster a team culture – Make sure that leadership is visible – the CEO is engaged, reports go to the Board, everyone is transparent about quality Make it difficult to do the wrong thing! • Create the system of care so that high quality of care does not rely solely on anyone’s memory – Create protocols, checklists, or pathways – Use of standing orders – Audit performance, provide feedback – Compare yourself to others Celebrate success! The caveat…… • Although performance on performance metrics can and should be high, the target may not always be 100% for some measures. To measure “perfect” performance, we would have to have perfect performance measures that address every possible clinical scenario that may justify deviation from the guideline upon which a measure is based. – Sometimes you do have to look at the details of a case or get expert help Clinical Infectious Diseases 2013;56(3):428–9. There’s no confusion about who “owns” quality Leaders are responsible for everything in an organization, especially what goes wrong. Paul O’Neill [email protected]